ERISA and Disability Benefits

Facts of the Case

Priscilla Glazer worked for The Ultimate Software Group as a senior technical writer. The Ultimate Software Group offered its employees long-term disability insurance under a plan provided by Reliance. According to the plan, an insured is “totally disabled” if he/she “cannot perform the substantial and material duties of his/her regular occupation.” Per the plan, Reliance had the discretion “to determine eligibility for benefits.”

Ms. Glazer experienced shoulder pain in 1996, leading to a diagnosis of numerous medical conditions, including myofascial pain syndrome, fibromyalgia, cervical spondylosis, chronic cervical strain, and radiculopathy. In June 2003, she stopped working, in accordance with the recommendations of her physician, Dr. Thomas Hoffeld. She also applied for disability benefits. Dr. Hoffeld's findings in the fall of 2003 documented that she had trouble with typing and sitting certain lengths of time. In January 2004, her disability application was approved by Reliance. Dr. Alan Novick started treating her in October 2003. In April, 2004, Dr. Hoffeld assessed her as still unable to return to work. However, in the subsequent month, Dr. Novick noted that her pain had been ameliorated.

Reliance's request to Ms. Glazer's physicians, Dr. Hoffeld and Dr. Novick, for her most current medical records as a part of re-examining her benefits in March 2004 was only responded to by Dr. Novick. In May 2004, Dr. Novick documented that Ms. Glazer, in addition to sedentary work, could now perform physical activities like simple grasping and fine manipulation (required for typing). In July 2004, after taking into consideration Dr. Novick's report, an interview with Ms. Glazer, and her job description, Reliance determined that she was capable of performing her occupation and her long-term disability benefits were terminated.

Ms. Glazer then went to see Dr. Benjamin Lechner, although she had not seen him since their last appointment in February 2003. Dr. Lechner reviewed her records and in his report noted that she could not use a computer and stated that her medical conditions rendered her “disabled for gainful employment.” Dr. Novick reported that she was feeling better in July 2004, and her condition was stable during her subsequent visits (November 2004, twice in February 2005, and March 2005), although she verbalized increased pain.

Dr. William Hauptman conducted an independent peer review of the medical records at the request of Reliance to help decide whether to terminate Ms. Glazer's benefits. Dr. Hauptman opined that her complaints of increased pain were not substantiated by medical evidence, that the reason for improvements in her physical capabilities after Dr. Hoffeld's 2003 evaluation were related to Dr. Novick's treatment, and that Dr. Novick's description of her capabilities (in May 2004) matched those described in the medical records.

After Ms. Glazer's disability application review, Reliance denied her application for long-term disability benefits. In response to Reliance's decision she filed a petition in the district court, the result of which was a summary judgment favoring the position taken by Reliance.

Ruling

Judge Pryor, writing for the Eleventh Circuit Court of Appeals, upheld the district court's summary judgment. The court of appeals ruled that Reliance had granted Ms. Glazer a “full and fair” review under the ERISA provisions and that the district court had implemented the correct standard of review in reaching its decision. The court concluded that Reliance rightly denied her application.

Reasoning

In its reasoning, the court explained Ms. Glazer's arguments, the issues, and the decision in three main points. In the first matter, Ms. Glazer argued that she had not been given a “full and fair review” of the denial of her application, per requirements by ERISA. She cited 29 C.F.R. § 2560.503-1(h)(2)(iii) (2007), which states that the administrator must “[p]rovide…upon request…all documents, records, and other information relevant to the claimant's claim for benefits” for the review to qualify as a “full and fair review.” She argued that Reliance had failed to provide her a copy of Dr. Hauptman's report while the review of the initial denial was pending. Reliance's answer to her argument was that it would only be required to provide her all the documents it had reviewed after a final decision was made. The appeals court concurred with Reliance. It cited Metzger v. UNUM Life Insurance Company of America, 476 F.3d 1161 (10th Cir. 2007), in its explanation that a plan administrator is not obliged to provide a plaintiff with medical reports before its final decision on appeal. The court noted that a requirement to produce the records before a final determination had been made would have been “superfluous” as it would create “an unnecessary cycle of submission, review, re-submission, and re-review” (Metzger, p 1166).

On the second matter, the court of appeals held that the district court had applied the correct standard of review in upholding Reliance's decision to deny Ms. Glazer's disability benefits. The court of appeals found that the applicable standard of review was a standard that examined whether the decision was “arbitrary and capricious” and whether there was a reasonable basis for Reliance's decision based on the facts that were known to it at the time.

The court of appeals, relying on several prior cases, found that regardless of whether the arbitrary and capricious review or the heightened form of that standard of review applies, the district court would have to make an independent review of the decision by the administrator to determine whether it was “wrong.” A decision is wrong if the court disagrees with the administrator's decision based on the court's fresh review and perspective (Williams v. Bellsouth Telecomm., Inc., 373 F.3d 1132 (11th Cir. 2004), p 1138). The court of appeals reasoned that there was no dispute about the information available in the record when Reliance made its decision, even if there was a disagreement about whether Ms. Glazer was disabled. The district court, which had reviewed the record, found that the decision by Reliance was right, which made analysis of whether Reliance's decision was arbitrary and capricious unnecessary. Thus, the court of appeals determined that the district court had been correct in the standard of review that had been applied.

The third question in the case involved the appellate court ruling that Reliance's denial of Ms. Glazer's disability benefits was correct. Since she bore the burden to prove that she was disabled, the appeals court agreed with the district court's finding that she failed in proving how her medical condition prevented her from conducting the “substantial and material” duties related to her work. Dr. Hoffeld's failure to respond to Reliance's request for updated medical records, the inadequacy of Dr. Hoffeld's and Dr. Lechner's reports in establishing a nexus between her physical disabilities and the demands of her work, the fact that Dr. Lechner had not seen her for more than a year at the time of formulating his report, which, furthermore, was incompatible with both Dr. Novick's and Dr. Hauptman's assessments, together provided enough evidence that she did not meet the disability criteria set by her insurance plan.

Discussion

The U.S. Supreme Court denied certiorari on December 1, 2008. Nevertheless, Glazer v. Reliance highlights the importance of a thorough assessment, while maintaining clinical objectivity in rendering opinions regarding disability. Very often, disability evaluations are performed by treating physicians who in addition to confronting a bias in trying to help the patient, may not perform an extensive record review and a detailed information analysis as a forensic clinician might. In rendering opinions, a treating clinician is at a risk of providing an assessment that may be based on partial information and is not fully substantiated by all medical evidence available. When treating clinicians are performing assessments for the purposes of disability determinations, they should be mindful of the fact that disability determinations are made by examining how medical symptoms affect the patient's occupational function. Therefore, descriptive language regarding symptoms and functioning can help establish a nexus that becomes an important factor in a disability determination.